Historial

Very high-speed single light vehicle road traffic accident; would appear to have fallen asleep at the wheel, frontal impact, trapped with instrument panel on knees.

At the arrival of the Fire department: conscious Glasgow = 15, blood pressure: 110/70 mmHg, heart rate: 100, saturation: 97% in 9 l of oxygen, in considerable pain, reactive intermediate pupils, Morphine titration during release, no signs of respiratory distress, soft abdomen, no guarding, no loss of distal sensitivity.
Dislocation fracture of the left elbow, fracture of the right wrist, open fracture of the left femur, possible fracture of the left foot. Hemodynamic stability during transport. The patient was sent directly to the university hospital for treatment.
At the university hospital: Stable hemodynamics, reactive and symmetric pupils, marked reduction in left breath sounds, pain at peripheral fractures and pain in lumbar spine, abdomen soft, compressible, painless.The body scan is provided.

Resultados

Thoracic space:
- Left diaphragmatic hernia with spleen, stomach, tail of pancreas, and left colonic flexure ascended into the intrathoracic position. No sign of distress of the migrated gastrointestinal segments.
- Parenchymatous opacification of almost the entire left lung (except for the anterior segments of the culmen) corresponding to passive parenchymatous atelectasis on the diaphragmatic rupture and probable contusions.
- Ventilatory disturbances of the right inferior lobe.- Left hemothorax.

- Fracture of the 6th to the 12th left ribs, anterior arch of the 3rd right rib and costochondral junctions of the 8th to the 10th right ribs.

Abdominopelvic space:
- Moderate hemoperitoneum.
- Subcapsular liver hematoma (segment IV).
- Splenic contusion and lacerations with no active bleeding.
- Left hemoretroperitoneum with hematoma of the renal hilus (centered on the renal vein) with no active bleeding. Occlusive dissection of the left renal artery with devascularization of the entire kidney.
- Possible contusion of the lateral branch of the left adrenal.- Burst fracture of L5 with no posterior wall recession.

- Also, characteristic image of mesenteric panniculitis and closure defect of the posterior arch of the sacrum.

Lower extremities:
- Comminuted fracture of the middle third of the left femoral diaphysis with no active bleeding.
- Left foot: fracture of the calcaneal articular facet at the calcaneo-cuboid joint.
Fracture of the lateral navicular cortex and comminuted fracture of the medial cuneiform bone.Avulsion fracture of the talonavicular ligament.

Dislocation fracture of the tarsometatarsal joint (LisFranc) and fracture of the diaphysis of the 1st metatarsal, and the head of the 2nd, 3rd and 4th metatarsals.

N.B.: dislocation fracture of the left elbow visible on the scout.

Diagnóstico

Debate

FOLLOW-UP:

- Emergency suture of the diaphragmatic wound with reintegration of the abdominal organs (15 cm posterior breach from the fleshy part of the diaphragm to the costal insertions). Perioperative exploration revealed a lateral, non-distended retroperitoneal hematoma predominating on the left associated with the renal injury (grade V). No associated lesions: right diaphragmatic cupola, small intestine, mesentery, colons, rectum and prevesical peritoneum intact. There was a subcapsular liver hematoma vertical to the anterior and superior face of segment IV to the right of the falciform ligament insertion. The left thoracic cavity contains the proximal half of the stomach, the greater omentum, the left part of the transverse colon, and the spleen. All of these internal organs were replaced in the abdominal cavity.

- Orthopedic treatment: osteosynthesis of the left femoral diaphysis (intramedullary pin), elbow, and left wrist, and of the left Lisfranc (open pinning). The L5 fracture was treated orthopedically with a corset for 3 months.

- For the dissection of the renal artery: there was no indication for revascularization or stenting given that the kidney injury is more than 4 hours old and that the endovascular procedure carries a high risk of hemorrhage.

- Simple monitoring of hepatic and splenic injuries.

Puntos clave

Important points:

- Diaphragmatic ruptures tend to be located on the left. In CT analysis, the “collar sign” (with thoracic herniation of intra-abdominal organs) and the “fallen sign” are good diagnostic indicators.

- A burst fracture = compression, damage to the anterior AND middle column, typical sagittal line, the stability depends on the extent of damage and posterior wall recession.